European Resuscitation Council Guidelines for Resuscitation ... - CPR

◦ Those experienced in clinical assessment should assess thecarotid pulse whilst simultaneously looking for signs of life fornot more than 10 s.◦ If the patient appears to have no signs of life, or if there isdoubt, start CPR immediately. Delivering chest compressionsto a patient with a beating heart is unlikely to cause harm. 240However, delays in diagnosis of cardiac arrest and starting CPRwill adversely effect survival and must be avoided.If there is a pulse or signs of life, urgent medical assessmentis required. Depending on the local protocols, this may takethe form of a resuscitation team. While awaiting this team, givethe patient oxygen, attach monitoring, and insert an intravenouscannula. When a reliable measurement of oxygen saturationof arterial blood (e.g., pulse oximetry (SpO 2 )) can be achieved,titrate the inspired oxygen concentration to achieve a SpO 2 of94–98%.If there is no breathing, but there is a pulse (respiratory arrest),ventilate the patient’s lungs and check for a circulation every 10breaths.Starting in-hospital CPR• One person starts CPR as others call the resuscitation team andcollect the resuscitation equipment and a defibrillator. If only onemember of staff is present, this will mean leaving the patient.• Give 30 chest compressions followed by 2 ventilations.• Minimise interruptions and ensure high-quality compressions.• Undertaking good-quality chest compressions for a prolongedtime is tiring; with minimal interruption, try to change the persondoing chest compressions every 2 min.• Maintain the airway and ventilate the lungs with the most appropriateequipment immediately to hand. A pocket mask, whichmay be supplemented with an oral airway, is usually readily available.Alternatively, use a supraglottic airway device (SAD) andself-inflating bag, or bag-mask, according to local policy. Trachealintubation should be attempted only by those who are trained,competent and experienced in this skill. Waveform capnographyshould be routinely available for confirming tracheal tubeplacement (in the presence of a cardiac output) and subsequentmonitoring of an intubated patient.• Use an inspiratory time of 1 s and give enough volume to producea normal chest rise. Add supplemental oxygen as soon as possible.• Once the patient’s trachea has been intubated or a SAD has beeninserted, continue chest compressions uninterrupted (exceptfor defibrillation or pulse checks when indicated), at a rate ofat least 100 min −1 , and ventilate the lungs at approximately10 breaths min −1 . Avoid hyperventilation (both excessive rateand tidal volume), which may worsen outcome. Mechanical ventilatorsmay free up a rescuer and ensure appropriate ventilationrates and volumes.• If there is no airway and ventilation equipment available, considergiving mouth-to-mouth ventilation. If there are clinicalreasons to avoid mouth-to-mouth contact, or you are unwillingor unable to do this, do chest compressions until help or airwayequipment arrives.• When the defibrillator arrives, apply the paddles to the patientand analyse the rhythm. If self-adhesive defibrillation pads areavailable, apply these without interrupting chest compressions.The use of adhesive electrode pads or a ‘quick-look’ paddles techniquewill enable rapid assessment of heart rhythm comparedwith attaching ECG electrodes. 241 Pause briefly to assess theheart rhythm. With a manual defibrillator, if the rhythm is VF/VTcharge the defibrillator while another rescuer continues chestcompressions. Once the defibrillator is charged, pause the chestcompressions, ensure that all rescuers are clear of the patient and18 de 0ctubre de 2010 www.elsuapdetodos.comC.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 1311then give one shock. If using an automated external defibrillation(AED) follow the AED’s audio-visual prompts.• Restart chest compressions immediately after the defibrillationattempt. Minimise interruptions to chest compressions. Using amanual defibrillator it is possible to reduce the pause betweenstopping and restarting of chest compressions to less than 5 s.• Continue resuscitation until the resuscitation team arrives or thepatient shows signs of life. Follow the voice prompts if using anAED. If using a manual defibrillator, follow the universal algorithmfor advanced life support (Section 4d).• Once resuscitation is underway, and if there are sufficient staffpresent, prepare intravenous cannulae and drugs likely to be usedby the resuscitation team (e.g., adrenaline).• Identify one person to be responsible for handover to the resuscitationteam leader. Use a structured communication tool forhandover (e.g., SBAR, RSVP). 97,98 Locate the patient’s records.• The quality of chest compressions during in-hospital CPR isfrequently sub-optimal. 242,243 The importance of uninterruptedchest compressions cannot be over emphasised. Even short interruptionsto chest compressions are disastrous for outcome andevery effort must be made to ensure that continuous, effectivechest compression is maintained throughout the resuscitationattempt. Chest compressions should commence at the beginningof a resuscitation attempt and continue uninterrupted unlessthey are briefly paused for a specific intervention (e.g., pulsecheck). The team leader should monitor the quality of CPR andalternate CPR providers if the quality of CPR is poor. ContinuousETCO 2 monitoring can be used to indicate the quality of CPR:although an optimal target for ETCO 2 during CPR has not beenestablished, a value of less than 10 mm Hg (1.4 kPa) is associatedwith failure to achieve ROSC and may indicate that the quality ofchest compressions should be improved. If possible, the personproviding chest compressions should be alternated every 2 min,but without causing long pauses in chest compressions.4d ALS treatment algorithmIntroductionHeart rhythms associated with cardiac arrest are divided intotwo groups: shockable rhythms (ventricular fibrillation/pulselessventricular tachycardia (VF/VT)) and non-shockable rhythms (asystoleand pulseless electrical activity (PEA)). The principal differencein the treatment of these two groups of arrhythmias is the need forattempted defibrillation in those patients with VF/VT. Subsequentactions, including high-quality chest compressions with minimalinterruptions, airway management and ventilation, venous access,administration of adrenaline and the identification and correctionof reversible factors, are common to both groups.Although the ALS cardiac arrest algorithm (Fig. 4.2) is applicableto all cardiac arrests, additional interventions may be indicated forcardiac arrest caused by special circumstances (see Section 8).The interventions that unquestionably contribute to improvedsurvival after cardiac arrest are prompt and effective bystanderbasic life support (BLS), uninterrupted, high-quality chest compressionsand early defibrillation for VF/VT. The use of adrenaline hasbeen shown to increase return of spontaneous circulation (ROSC),but no resuscitation drugs or advanced airway interventions havebeen shown to increase survival to hospital discharge after cardiacarrest. 244–247 Thus, although drugs and advanced airways are stillincluded among ALS interventions, they are of secondary importanceto early defibrillation and high-quality, uninterrupted chestcompressions.As with previous guidelines, the ALS algorithm distinguishesbetween shockable and non-shockable rhythms. Each cycle iswww.elsuapdetodos.com